Faculty Bibliography

Brain death, or death by neurologic criteria (BD/DNC), is the permanent loss of brain function, defined by coma with loss of capacity for consciousness and complete brainstem areflexia, including the inability to breathe spontaneously. The 2023 American Academy of Neurology/American Academy of Pediatrics/Child Neurology Society (CNS)/Society for Critical Care Medicine guidelines state that pregnancy is not a contraindication for BD/DNC evaluation. Clinical evaluation of BD/DNC includes an apnea test to demonstrate the absence of spontaneous respiratory effort in response to hypercapnia and acidosis. The safety of apnea testing to the fetus in pregnant patients remains uncertain.We convened a panel of experts in BD/DNC, neurocritical care, maternal-fetal medicine, neonatology, fetal/neonatal/child neurology, and pediatric/fetal anesthesiology to perform a scoping review of apnea testing in pregnant persons. We found no studies directly assessing safety of apnea testing on the fetus. Apnea testing consists of fetal exposure to parental hyperoxia and hypercapnia; therefore, we searched for evidence related to these conditions in pregnancy. Case reports, series, and literature on physiologic changes induced during apnea testing and their potential effects on placental, fetal systemic, and fetal cerebral circulations were identified. In reported cases of BD/DNC in pregnant persons, some authors described explicitly avoiding apnea testing because of safety concerns, but whether apnea testing was performed at all was inconsistently reported. Evidence from studies evaluating hyperoxia and hypercapnia in healthy pregnant persons and in other animal models suggested possible adverse effects caused by reduced uteroplacental blood flow, fetal metabolic acidosis, and hypercapnia-induced cerebral hyperperfusion. Further possible complications of apnea testing, such as hypotension or hypoxemia in pregnant persons, could also contribute to fetal injury. These potential detrimental risks to the fetus raise the question as to whether apnea testing should be deferred if a fetus may be viable. Ancillary tests, such as radionuclide cerebral blood flow imaging or transcranial Doppler ultrasonography, can be used if the remainder of the BD/DNC evaluation and neurologic examination is otherwise consistent with BD/DNC. Further research is essential to assess the physiologic consequences of apnea testing in pregnant persons and potential risks to the fetus.

BACKGROUND:The Uniform Determination of Death Act requires brain death/death by neurologic criteria (BD/DNC) determination to be in accordance with "accepted medical standards." The medical organizations responsible for delineating these guidelines are only specified statutorily in two states. State health organizations (SHOs) are composed of policy experts and medical professionals who are responsible for addressing medical, ethical, and legislative problems related to health. We sought to evaluate information publicly available on SHO websites regarding BD/DNC. METHODS:From December 2023 to August 2024, we searched SHO (health department, medical board, medical society, and hospital association) websites for the 48 states without statutory guidance regarding what constitutes accepted medical standards for information regarding BD/DNC using the terms "brain death," "brain stem," and "determination of death." All posts related to BD/DNC were reviewed and categorized via thematic analysis. RESULTS:Of the 192 SHO websites searched, there were 35 from 28 states that provided information regarding BD/DNC: 14 medical societies, 12 health departments, 8 hospital associations, and 1 medical board. Of these 35 SHOs, 12 referenced the state's legal statute, 11 referenced hospital/state/model policies or guidance, 3 referenced both legal statutes and hospital/state/model policies or guidelines, 3 referenced explicit support for standardized BD/DNC guidelines, and 6 made other mention of BD/DNC. New York was the only state with an SHO that provided clear guidance regarding accepted medical standards for BD/DNC determination. CONCLUSIONS:For most states, the accepted medical standards for BD/DNC determination are not identified on SHO websites or statutorily. This contributes to inconsistencies across hospital BD/DNC determination policies, leading to medical, ethical, and legal challenges. Delineation of the accepted medical standards for BD/DNC determination in each state could help facilitate consistency and accuracy in BD/DNC determination, prevent false positive determinations of death, and promote public trust in BD/DNC determination and the medical system overall.

Brain death/death by neurologic criteria (BD/DNC) is accepted as legal death throughout much of the world. The World Brain Death Project and a subsequent review of the literature through 2023 highlighted several medicolegal controversies related to BD/DNC in Canada, the United Kingdom, and the United States but did not discuss medicolegal controversies related to BD/DNC in low- and middle-income countries, such as India. Although the Transplantation of Human Organs Act of 1994 acknowledged BD/DNC as death in India, BD/DNC evaluations are not always completed when BD/DNC is suspected. This has been attributed to lack of awareness/acceptance by medical professionals, lack of public awareness/acceptance of BD/DNC, communication challenges, fear, time limitations, and the inclusion of BD/DNC in organ donation law (but not general law). There has been a gradual rise in the number of donations after BD/DNC (a correlate for the number of BD/DNC determinations) in southern and western states, but the number of donations after BD/DNC has decreased in the southwestern state of Kerala in the setting of recent medicolegal controversies. This article reviews the history of BD/DNC determination in India as a whole, then describes the recent medicolegal controversies related to BD/DNC in the state of Kerala. Finally, these controversies are contextualized relative to the aforementioned controversies in high-income countries. Three key international themes of medicolegal controversies related to BD/DNC are regulation, religion, and resource allocation. The global neurocritical care community must advocate for consistency and accuracy in BD/DNC determination and collaborate with legal and policy experts to develop means to mitigate these challenges through revisions to the law, standardization of practice and policies, education, and communication.

Severe brain injury can result in disorders of consciousness (DoC), including coma, vegetative state/unresponsive wakefulness syndrome, and minimally conscious state. Improved emergency and trauma medicine response, in addition to expanding efforts to prevent premature withdrawal of life-sustaining treatment, has led to an increased number of patients with prolonged DoC. High-quality bedside care of patients with DoC is key to improving long-term functional outcomes. However, there is a paucity of DoC-specific evidence guiding clinicians on efficacious bedside care that can promote medical stability and recovery of consciousness. This Viewpoint describes the state of current DoC bedside care and identifies knowledge and practice gaps related to patient care with DoC collated by the Care of the Patient in Coma scientific workgroup as part of the Neurocritical Care Society's Curing Coma Campaign. The gap analysis identified and organized domains of bedside care that could affect patient outcomes: clinical expertise, assessment and monitoring, timing of intervention, technology, family engagement, cultural considerations, systems of care, and transition to the post-acute continuum. Finally, this Viewpoint recommends future research and education initiatives to address and improve the care of patients with DoC.

BACKGROUND:Intubated neuroscience ICU patients are at risk for unplanned extubation (premature removal of the endotracheal tube by the patient or during patient care). The incidence of unplanned extubation is an indicator of the quality of ICU care. Unplanned extubation is a risk factor for pneumonia, increased ventilator days, the need for tracheostomy and increased ICU and hospital length-of-stay. After serial unplanned extubations, we introduced a multidisciplinary unit-based practice standard to reduce unplanned extubations as part of a quality improvement initiative in the neuroscience ICU in a large academic medical center at a High Reliability Organization in May 2021. The unit-based practice standard to guide care of intubated neuroscience ICU patients focused on communication, timely escalation of concerns, use of sedation/analgesia targeting RASS ≤ -1, soft wrist restraints (unless specified exclusion criteria met) and continuous observation for patients at high risk of agitation/restlessness. We sought to determine the impact of this initiative on the incidence of unplanned extubations. METHOD/METHODS:Unplanned extubations were identified via retrospective audit of prospective incident reports from our Patient Safety Incident registry pre-initiative (June 2020-May 2021) and prospective audit of incident reports post-initiative (July 2021-March 2024). Chart review facilitated collection of data on patient age, sex, diagnosis, intubation day, RASS goal, sedation/analgesia, restraints, constant observation, shift, and reintubation. The total number of intubated patients and ventilator days during these timeframes was identified retrospectively via an electronic medical record report of all patients on ventilators in the neuroscience ICU. RESULTS:During the pre-initiative audit period, there were 214 intubated patients (968 ventilator days). The audit identified 9 unplanned extubations (0.93/100 ventilator days; 8 males, median age 63-years-old (IQR 47-67)). There were 4 patients who were not ordered for sedation/analgesia or had a RASS goal of 0 and no patients were in nonviolent soft wrist restraints. During the post-initiative audit period, there were 576 intubated patients (2,730 ventilator days). The audit identified 6 unplanned extubations (0.22/100 ventilator days; 6 males, median age 53-years-old (IQR 27-78)). All 6 patients had a RASS goal ≤ -1 and were in nonviolent soft wrist restraints. CONCLUSION/CONCLUSIONS:This quality improvement initiative effectively reduced the incidence of unplanned extubations in our neuroscience ICU.

BACKGROUND:Hemorrhagic stroke survivors may have cognitive impairment. We sought to identify preadmission and admission factors associated with cognitive impairment after hemorrhagic stroke. DESIGN/METHODS:Patients with nontraumatic intracerebral or subarachnoid hemorrhage (ICH or SAH) were assessed 3-months post-bleed using the Quality of Life in Neurological Disorders (Neuro-QoL) Cognitive Function short form. Univariate and multivariate analysis were used to evaluate the relationship between poor cognition (Neuro-QoL t-score ≤50) and preadmission and admission factors. RESULTS:Of 101 patients (62 ICH and 39 SAH), 51 (50 %) had poor cognition 3-months post-bleed. On univariate analysis, poor cognition was associated with (p < 0.05): age [66.0 years (52.0-77.0) vs. 54.5 years (40.8-66.3)]; private insurance (37.3 % vs. 74.0 %); BMI > 30 (13.7 % vs. 34.0 %); and admission mRS score > 0 (41.2 % vs. 14.0 %), NIHSS score [8.0 (2.0-17.0) vs. 0.5 (0.0-4.0)], and APACHE II score [16.0 (11.0-19.0) vs. 9.0 (6.0-14.3)]. On multivariate analysis, poor cognition was associated with mRS score > 0 [OR 4.97 (1.30-19.0), p = 0.019], NIHSS score [OR 1.14 (1.02-1.28), p = 0.026], private insurance [OR 0.21 (0.06-0.76), p = 0.017] and BMI > 30 [OR 0.13 (0.03-0.56), p = 0.006]. CONCLUSIONS:Cognitive impairment after hemorrhagic stroke is less common in patients with BMI > 30 and private insurance. Heightened surveillance for non-obese patients without private insurance is suggested. Additional investigation into the relationship between cognition and both BMI and insurance type is needed.